Monitoring questions for residential and community substance misuse services

• Are infection risks to people using the service being thoroughly assessed and managed?
• Have you changed the layout/environment of clinical and non-clinical areas to continue to provide services safely in this period? For example, clean sites, separate entrances and waiting areas for known/suspected COVID patients, additional signage, spaces between stations, isolation facilities, ensuring compliance with best practice guidance when visiting people in their own homes etc.
• Do you have the resources to obtain, and reliable access to, all the supplies, personal protective equipment and COVID-19 testing needed for both staff and, where appropriate, people who use the service?
• Are working arrangements and procedures clear and accessible to staff, people who use the service, their supporters and, where appropriate, visitors to the service?
• Are people using the service being protected from abuse, neglect, discrimination and loss of their human rights?
• Where applicable, have you identified when they may be depriving a person of their liberty, and followed the correct and lawful procedures, for example DoLS application, Court of Protection?
• Are your safeguarding and other policies and practice, together with local systems, properly managing any concerns about abuse and protecting people’s human rights?

• Are risks to the health and wellbeing of people using your service being properly assessed, monitored and managed?
• Do staff have the appropriate skill mix and experience to provide safe care and treatment in a dignified and respectful way?
• Are escalation plans in place in response to surges in demand, for example second wave, seasonal pressures?
• How are you identifying and managing risks for patients including any restrictive practices or issues affecting their legal or human rights?

• Do you have access to - and are following - guidelines around Treatment Escalation Plans (TEPs), anticipatory care planning, Do Not Attempt CPR (DNACPR) orders and individualised care plans?
• Are plans in place for rapid transfer to preferred places of care - relationships and planning with primary care, district nursing etc
• Can you effectively manage referrals and, where relevant, discharges and ensure safe transfers of care?
• Where relevant, what testing arrangements are in place, and how do you handle transfers of known/suspected COVID patients safely?
• How are you working with other partners?

S3. Additional prompts for substance misuse services

• Residential settings: What changes have been made to admissions protocols and processes in light of the COVID-19 pandemic?
• Community settings: How are assessments and referrals being managed with limited access to services

• Are medicines being managed safely and effectively?
• Covid-19 impacted your ability to manage medicines?

S4. Additional prompts for substance misuse services

Community settings

• Can you give examples of how medicines are being managed safely and effectively?
• What processes are in place to ensure clients on supervised daily consumption have been moved safely to alternative prescribing or collection frequencies (moving from daily to less frequent dispensing) to allow for social distancing and protection of the vulnerable?
• How have you liaised with pharmacies to monitor client safety?
• Does COVID-19 continue to impact on your ability to manage medicines?
• How are you working with other providers to ensure continuity of care? Is there a three-way conversation between SMS, community pharmacy and commissioners, as well as community mental health teams where applicable?

Residential settings

• Can you give examples of how medicines are being managed safely and effectively?
• What processes are in place to ensure clients’ clinical needs are assessed on admission and monitored during their stay?
• Does COVID-19 continue to impact on your ability to manage medicines?

• Are there any significant trends in non COVID-19 activity - Never Events, Significant Incidents, themes in incidents, Mortality, Unexpected deaths?
• What are you doing to assess and learn, including mortality reviews of non-COVID patients?
• Are there any significant trends where groups of patients are faring worse in terms of safety concerns?

• How are you identifying, cascading and keeping up-to-date with changes in clinical guidance?
• Where people are subject to the Mental Health Act (MHA), how are you ensuring compliance with the MHA?

• How are you collecting information about people's care treatment and outcomes?
• Where relevant, are you continuing to submit to relevant national clinical audits?
• How are outcomes being monitored for groups of people that may be at higher risk of contracting COVID-19, for example different ethnic groups and older people?

• How are you ensuring that all staff, including those being flexibly re-deployed, have the skills and training to carry out their roles effectively?

• How are you ensuring that the necessary staff, teams and services are involved in assessing, planning and delivering peoples care and treatment, including working with mental health teams?

• How do you ensure consent to care and treatment is always sought in line with legislation and guidance? Including, where appropriate:
  • ensuring that people are involved in decisions about not providing care and treatment, including advanced care plans and DNACPR decisions?
  • promoting supportive practice that avoids the need for physical restraint? Where physical restraint may be necessary, how do you ensure that it is used in a safe, proportionate, and monitored way as part of a wider person-centred support plan?
• Ensuring staff apply relevant legislation where people may lack capacity to consent to particular care and treatment, including the Mental Capacity Act 2005 (including DoLS) and the Children’s Acts 1989 and 2004?

• How have you adapted how you support and engage with patients and their families/loved ones?
• How do you ensure the care delivered is compassionate and upholds people's human rights?

C1. Additional prompts for substance misuse services

Residential settings

• How are you managing visitors during the pandemic, taking into account government guidance regarding restrictions?

• How do you support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?
• Where appropriate, how are you managing the impacts of limited visiting on patient's wellbeing?
• Where appropriate, how are you promoting and ensuring patients know how to access advocacy support in the absence of ward visits?

• How do you ensure that you meet the needs of the population served and do you enable flexibility, choice and continuity of care (including signposting to mutual aid groups – possibly held virtually - where appropriate)?
• Where relevant, do individual patients have choices about how, when and where they are seen?

• How are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances? This may include:
  • How do you ensure that each patient has their information and communication needs identified, recorded, flagged, shared and met?
  • How do you identify and make other reasonable adjustments for disabled people?
• Where new protocols for admission are being used, how are these being communicated to staff and how are they reviewed to ensure they are non-discriminatory?

• How are you managing access to the service to ensure that high-risk patients/pathways are being identified and prioritised appropriately, including reinstating services and handling backlogs of activity?
• Is there a structured approach to patient flow that ensures all components of the system are appreciated and managed appropriately, and flow issues are escalated appropriately? How does the approach take account of the pandemic, for example the impact of testing at admission?

R3. Additional prompts for substance misuse services

Residential settings

• Are there isolation options pending delay in discharge/transfer?

• Has there been any impact on leadership capacity as a result of the COVID-19 crisis? Are there plans and mitigations in place should it be affected?
• Do leaders understand the challenges to quality and sustainability during this period, and can they identify the actions needed to address them?

• Are you monitoring and protecting the health, safety and wellbeing of staff?
• How are you taking action to protect the health, safety and wellbeing of staff, for example access to emotional support, supporting staff to raise concerns, adequately risk-assessing and placing staff in appropriate environments to protect their health and safety, including staff in different ethnic groups and other staff at high risk of COVID-19? (not for NHS trusts - this covered at trust level)

• Can you work effectively with system partners when care and treatment is being commissioned, shared or transferred?

• Do you have effective systems and methods for monitoring the overall quality of the service and for responding to business risks and issues as they arise? How often are these reviewed?